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ID#:
Student Name:
Date of
Birth:
Date:
Contact Information:
Teacher Name:
Grade:
Parent Name(s)
Parent Phone:
Home
Work
Cell
Problem
Behaviors
Aggressive
Non compliant
Poor attention
Easily distracted
Destroys property
Steals/Cheats/lies
Avoided by peers
Argumentative/D
efiant
Work completion
Withdrawn
Disruptive
Poor attendance
Bullies others
Victim of Bullying
Other _________
Communicat
ion
Language
Fluency
Articulation
Voice
ELL
other
Personal Care
dressing
hygiene
organization
glasses
Agitated/Nerv
ous
Sleeps in
class
Obese
Under-weight
Uncoordinate
d
Evidence of
selfmutilation
Burn marks
Appears
sickly
other
Health
visual
acuity
visual
tracking
hearing
physical
seizures
medication
gross/fine
motor
other
Contributing
Factors
curriculum
trauma
personal
loss
anxiety
peers
family
truant
tardy
other
Other Comments/Concerns:
Positive Attributes/Strengths:
Positive Attitude
Hard working
Trustworthy
Works well in
groups
Works well
independently
Self-confident
Takes pride in work
High expectations
of self
Organized
Good sense of
humor
Cooperates
Responsible
Creative
Has leadership
qualities
Transitions easily
Takes pride in
appearance
Athletic
Musically talented
Artistically
talented
Accepts
suggestions
Kind to classmates
Popular with
classmates
Good memory
skills
Completes
homework
Respectful toward
adults
Enjoys helping
others
Articulate
Problem solving
skills
Takes/follows
directions well
Strategies and Results: Check all that apply and provide any results for most effective strategies
tried.
General
Review
Review files
Talk w/ parent
Talk w/
previous
teacher
Seek peer
help
Classroom
Assessment
Modified
Environmen
t
Change
Seat
Provide
quiet space
Provide
larger space
Encourage
work breaks
other
Modified
Presentatio
n
pre-teach
give extra
practice
change
pacing
give extra
feedback
provide
patterns
vary
Modified
Curriculum/
HW
change task
size
change color
provide
computer
provide
calculator
use visuals/
manipulative
s
Modified
Expectation
s
group
product
individ.
Product
make it
easier
more time
tutor/mentor
alternate
response
Results
materials
increase
instructional
time
planned
positive
reinforce
other
change
instruction
provide a
model
other
emphasize
quality over
quatity
other
Behavior Plan
SpEd Referral
Other:
Teachers bring the following to the SSST meeting: Work samples, assessment scores, reading
rate/accuracy, anecdotal notes, incident reports, other data. This information can be attached to this
form. Please see the Student Data and Evidence page for suggested data.
Work attached.
ID#:
Student Name:
Date of
Birth:
Date:
Contact Information:
Teacher Name:
Grade:
Parent Name(s)
Parent Phone:
Home
Work
Cell
Frequency &
Duration
Person
Responsible
Progress Monitoring
Evidence (attach notes,
meetings, assessment
documentation, work
samples, etc. as
appropriate)